Form 10-10068a Camp Lejeune Family Member Program Claim Form

OMB Number 2900-XXXX
Burden Hours: 15 minutes
OMB EXP Date: XX/XX/XXXX

Department of Veterans Affairs

Camp Lejeune Family Member Program Claim Form

Attention: After reviewing the following information, complete the form in its entirety (print or type only), and return with the
itemized billing statements to the Department of Veterans Affairs, Financial Services Center, PO Box 149200, Austin TX, 78714-9200. Customer
Service Center: 1-866-372-1144, Fax: 512-460-5536.
Claim form usage: This form is to be completed by the patient, sponsor, or guardian and is mandatory for all beneficiary claims. This claim
form is NOT to be used for provider submitted claims.
Other health insurance (OHI): If OHI exists, attach OHI’s Explanation of Benefits (EOB) to the provider’s itemized billing statement(s).
Dates of service and provider charges on EOB must match billing statements.
Timely filing requirement: Claims must be received no later than two years after the date of service or, in the case of inpatient care, within
two years of the discharge date.
Itemized billing statements: An itemized statement must be attached and contain:
• patient name, date of birth, and Member Number (same as patient’s Social Security number);
• provider name, degree, tax identification number (TIN), address and telephone number; and
• service dates, itemized charges and appropriate procedure/diagnosis codes for each service (i.e. CPT-4, HCPCS, and ICD-9-CM
codes), including narrative descriptions. Pharmacy claims are to include name, quantity, strength, and NDC of each drug.

Section I - Patient Information

First Name

Last Name

MI

Street Address

Social Security Number

Date of Birth (mm/dd/yyyy)

Check if New
City

State

Zip Code

Telephone Number (include area code)

Section II - Other Health Insurance (OHI) Information

By law, other coverage must be reported. If more space is needed, please continue in the same format on a separate sheet.
• Was treatment for a work-related injury
or condition?
Yes
No
• Was treatment for an injury or accident
outside of work?
Yes
No
• Are you covered by other primary health
insurance to include coverage through a
family member (supplemental or
secondary insurance excluded)?
Yes (check type below and provide
coverage information on the right)
employer sponsored (group)
private (non group)
Medicare (Part A or B)
other (specify)

Name of Other Health Insurance (OHI)

OHI Policy Number

OHI Telephone Number (include area code)

Name of Other Health Insurance (OHI)

OHI Policy Number

OHI Telephone Number (include area code)

no (proceed to Section III)

Section III - Veteran Information
Last Name

First Name

MI

Social Security Number

Section IV - Claimant Certification

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious, or fraudulent statements or claims.
Date
Signature (type if electronic)
I certify that the above information and attachments are correct
and represent actual services, dates, and fees charged. (Sign and
date on right.) If certification is signed by a person other than the
patient, complete the information the signature and date.

4

MI

First Name

Last Name

Relationship to Patient

Street Address

City

VA Form
JUL 2013

State

10-10068a

ZIP Code

Telephone Number (include area code)

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Camp Lejeune Family Member Program Claim Form (Continued)
The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be
aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is
to determine eligibility for benefits.
Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The
purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions
determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least
30 days. The information you provide may be verified by computer matching programs with authoritative sources such as
the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Department of Defense
(DoD), Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any
other applicable authoritative source at any time. You are requested to provide your social security number as your VA
record is filed and retrieved by this number. The responses you submit are considered private and may be disclosed
outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system
of records number 23VA16. For example, information including your social security number may be disclosed to the
Department of Defense, contractors, trading partners, health care providers and other suppliers of health care services to
determine your eligibility for medical benefits and payment for services.

VA Form
JUL 2013

10-10068a

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